Table of Contents

 

Dislocations of the hip, knee, or ankle are painful presentations in the trauma ED that must be managed quickly to avoid morbidity, disability, and even possible amputation. This issue presents an evidence-based approach to:

Quickly assess the dislocation based on the mechanism of injury

Manage fractures often associated with dislocations

Quickly and safely diagnose and treat dangerous knee dislocations

Order diagnostic studies to determine the exact nature of the dislocation: x-rays or CT?

Decide whether to immediately reduce the dislocation, or whether urgent surgical consultation is needed first

Choose the best methods for reduction, based on provider and patient needs

Correctly disposition the patient: do all patients need to be admitted?

1. Abstract
2. Case Presentations
3. Introduction
4. Critical Appraisal of the Literature
5. Etiology and Pathophysiology
   1. Hip Dislocation
   2. Knee Dislocation
   3. Ankle Dislocation
6. Differential Diagnosis
   1. Hip Dislocation
   2. Knee Dislocation
   3. Ankle Dislocation
7. Prehospital Care
8. Emergency Department Evaluation
   1. Hip Dislocation
   2. Knee Dislocation
   3. Ankle Dislocation
9. Diagnostic Studies
   1. Hip Dislocation
   2. Knee Dislocation
   3. Ankle Dislocation
10. Treatment
    1. Hip Dislocation
    2. Reduction of Hip Dislocation
    3. Knee Dislocation
    4. Reduction of Knee Dislocation
    5. Ankle Dislocation
       1. Reduction of Ankle Dislocation
11. Disposition
    1. Hip Dislocation
    2. Knee Dislocation
    3. Ankle Dislocation
12. Complications
    1. Hip Dislocation
    2. Knee Dislocation
    3. Ankle Dislocation
13. Special Circumstances
    1. Hip Dislocation Following Total Hip Arthroplasty
    2. Knee Dislocation Following Knee Replacement
    3. Patellar Dislocation
    4. Knee Dislocation in Children
14. Controversies and Cutting Edge
    1. Ultrasound-Guided Procedural Sedation
15. Summary
16. Key Points
17. Risk Management Pitfalls in Management of Lower-Extremity Dislocation
18. Time- and Cost-Effective Strategies
19. Case Conclusions
20. Clinical Pathways
    1. Clinical Pathway for Emergency Department Management of Suspected Hip Dislocation
    2. Clinical Pathway for Emergency Department Management of Suspected Knee Dislocation
    3. Clinical Pathway for Emergency Department Management of Suspected Ankle Dislocation
21. Tables and Figures
    1. Table 1. Differential Diagnosis for Traumatic Hip Pain
    2. Table 2. Differential Diagnosis of Ankle Dislocation
    3. Table 3. Injuries Associated With Traumatic Hip Dislocation
    4. Table 4. Complications of Ankle Dislocation
    5. Figure 1. Blood Supply of the Femoral Head
    6. Figure 2. Anatomy of the Knee
    7. Figure 3. An Irreducible Lateral Knee Dislocation That Demonstrates Dimpling
    8. Figure 4. Major Nerves of the Knee
    9. Figure 5. Ankle Joint Ligaments
    10. Figure 6. Posterior Hip Dislocation With Fracture of Acetabular Wall
    11. Figure 7. X-Ray Images of Knee Dislocations
    12. Figure 8. Ankle Dislocations
    13. Figure 9. The Allis Method
    14. Figure 10. The Bigelow Method
    15. Figure 11. The Captain Morgan Technique
    16. Figure 12. The Rocket Launcher Technique
    17. Figure 13. Patellar Dislocations
22. References

Abstract

Case Presentations

A 25-year-old man is brought in by ambulance after being involved in a high-speed motor vehicle crash as an unrestrained driver. He is complaining of right hip pain and lower abdominal pain. During his primary trauma survey, you note that his right leg is shortened and internally rotated. You suspect a native hip dislocation and/or fracture and wonder which diagnostic studies you should obtain and whether you should attempt a reduction before consulting orthopedic surgery.

Later that evening, an elderly woman arrives with right hip pain, unable to ambulate. She states, “I was just bending over to put on my shoes when I felt a ‘pop,’ and then I fell to the ground.” She then informs you that she recently underwent right total hip arthroplasty. You notice her right leg appears internally rotated, adducted, and shortened. You suspect a dislocation of her prosthesis and wonder whether you should involve orthopedics or reduce it yourself and, if reduction is successful, whether she can be discharged home.

19-year-old man arrives by EMS, saying that while he was playing a pick-up game of football, he was tackled and felt a “pop” in his right knee. His friend told EMS that his knee looked like it “bent backwards.” His knee was immobilized by EMS, but it doesn’t look deformed. You are concerned that he may have dislocated and spontaneously reduced his knee and wonder if any diagnostic studies are needed.

A 27-year-old man presents to the ED with right ankle pain and obvious deformity. He has severe pain and cannot stand after landing awkwardly in a hole with his right foot when he jumped down from a tree branch. He is unable to bear weight or move his ankle due to severe pain. He appears to have an ankle dislocation and possible fracture; you wonder which takes priority: reduction or imaging?

Introduction

Critical Appraisal of the Literature

A literature search was performed in PubMed, EMBase, Medline^®, Allied and Complementary Medicine Database, SportDiscus, and Google Scholar using the search terms hip dislocation, anterior hip dislocation, posterior hip dislocation, knee dislocation, ankle dislocation, talar dislocation, subtalar dislocation, hip reduction, knee reduction, and ankle reduction. A total of 163 articles were found regarding hip dislocations, 187 on knee dislocations, and 167 on ankle dislocations. The Cochrane Database of Systematic Reviews was searched, using the terms hip dislocation, knee dislocation, and ankle dislocation, resulting in 8 articles related primarily to knee dislocations. The American College of Emergency Physicians does not endorse any guidelines related to lower-extremity dislocations.

The majority of the applicable literature for lower-extremity dislocations is found in orthopedic and trauma surgery journals. ED-specific studies are limited, though the approach and initial management is the same, regardless of location or provider. Most of the articles in the literature are case reports, case series, and retrospective reviews; there are no large randomized trials assessing diagnosis or management strategies for lower-extremity dislocations.

References

Evidence-based medicine requires a critical appraisal of the literature based upon study methodology and number of subjects. Not all references are equally robust. The findings of a large, prospective, randomized, and blinded trial should carry more weight than a case report.

To help the reader judge the strength of each reference, pertinent information about the study is included in bold type following the reference, where available. In addition, the most informative references cited in this paper, as determined by the authors, are noted by an asterisk (*) next to the number of the reference.

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15. Monahan TJ. Management of acute and chronic nerve injuries in the multiple ligament injured knee. Sports Medicine and Arthroscopy Review. 2001;9(3):227-238. (Review)
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17. Georgilas I, Mouzopoulos G. Anterior ankle dislocation without associated fracture: a case with an 11 year follow-up. Acta Orthop Belg. 2008;74(2):266-269. (Case report; 1 patient)
18. Gogi N, Khan SA, Anwar R. Anterior dislocation of the tibio-talar joint without diastasis or fracture--a case report. Foot Ankle Surg. 2008;14(1):47-49. (Case report; 1 patient)
19. Rivera F, Bertone C, De Martino M, et al. Pure dislocation of the ankle: three case reports and literature review. Clin Orthop Relat Res. 2001(382):179-184. (Case series; 3 patients)
20. Lertwanich P, Santanapipatkul P, Harnroonroj T. Closed posteromedial dislocation of the ankle without fracture: a case report. J Med Assoc Thai. 2008;91(7):1137-1140. (Case report; 1 patient)
21. Mazur JM, Loveless EA, Cummings RJ. Ankle dislocation without fracture in a child. Am J Orthop (Belle Mead NJ). 2007;36(9):E138-E140. (Case report; 1 patient)
22. Tarantino U, Cannata G, Gasbarra E, et al. Open medial dislocation of the ankle without fracture. J Bone Joint Surg Br. 2008;90(10):1382-1384. (Case report; 1 patient)
23. Distefano S, Divita G. A case of pure dislocation of the ankle joint. Ital J Orthop Traumatol. 1988;14(1):133-137. (Case report; 1 patient)
24. Finkemeier C, Engebretsen L, Gannon J. Tibial-talar dislocation without fracture: treatment principles and outcome. Knee Surg Sports Traumatol Arthrosc. 1995;3(1):47-49. (Case report; 1 patient)
25. Greenbaum MA, Pupp GR. Ankle dislocation without fracture: an unusual case report. J Foot Surg. 1992;31(3):238-240. (Case report; 1 patient)
26. * Wroble RR, Nepola JV, Malvitz TA. Ankle dislocation without fracture. Foot Ankle. 1988;9(2):64-74. (Case series; 8 patients)
27. Melenevsky Y, Mackey RA, Abrahams RB, et al. Talar fractures and dislocations: a radiologist’s guide to timely diagnosis and classification. Radiographics. 2015;35(3):765-779. (Review)
28. * Wagner R, Blattert TR, Weckbach A. Talar dislocations. Injury. 2004;35 Suppl 2:Sb36-Sb45. (Review)
29. Abu-Laban R, Rose N. Foot and Ankle. In: Marx J, Hockenberg R, Walls R, eds. Rosen’s Emergency Medicine - Concepts and Clinical Practice. 8th ed. Philadelphia, PA: Saunders; 2013:723-750. (Textbook chapter)
30. Moehring HD, Tan RT, Marder RA, et al. Ankle dislocation. J Orthop Trauma. 1994;8(2):167-172. (Review)
31. Karampinas PK, Kavroudakis E, Polyzois V, et al. Open talar dislocations without associated fractures. Foot Ankle Surg. 2014;20(2):100-104. (Case series; 9 patients)
32. * Weston JT, Liu X, Wandtke ME, et al. A systematic review of total dislocation of the talus. Orthop Surg. 2015;7(2):97-101. (Systematic review; 86 patients)
33. Syed AA, Agarwal M, Dosani A, et al. Medial subtalar dislocation: importance of clinical diagnosis in distinguishing from other dislocations. Eur J Emerg Med. 2003;10(3):232-235. (Review)
34. Rammelt S, Goronzy J. Subtalar dislocations. Foot Ankle Clin. 2015;20(2):253-264. (Review)
35. Dean DB. Field management of displaced ankle fractures: techniques for successful reduction. Wilderness Environ Med. 2009;20(1):57-60. (Review)
36. Wood GC, McLauchlan GJ. Outcome assessment in the elderly after total hip arthroplasty. J Arthroplasty. 2006;21(3):398-404. (Randomized controlled trial; 99 patients)
37. Tabuenca J, Truan JR. Knee injuries in traumatic hip dislocation. Clin Orthop Relat Res. 2000;(377):78-83. (Retrospective study; 187 patients)
38. * Barnes CJ, Pietrobon R, Higgins LD. Does the pulse examination in patients with traumatic knee dislocation predict a surgical arterial injury? A meta-analysis. J Trauma. 2002;53(6):1109-1114. (Meta-analysis; 7 studies; 284 injuries)
39. Klimke A, Furin M. Prehospital Immobilization. In: Roberts JR, ed. Roberts and Hedges’ Clinical Procedures in Emergency Medicine. 6th ed. Philadelphia, PA: Elsevier; 2014:893-922. (Textbook chapter)
40. * Georgiadis AG, Guthrie ST, Shepard AD. Beware of ultra-low-velocity knee dislocation. Orthopedics. 2014;37(10):656-658. (Review)
41. Gray JL, Cindric M. Management of arterial and venous injuries in the dislocated knee. Sports Med Arthrosc. 2011;19(2):131-138. (Review)
42. Mills WJ, Barei DP, McNair P. The value of the ankle-brachial index for diagnosing arterial injury after knee dislocation: a prospective study. J Trauma. 2004;56(6):1261-1265. (Prospective study; 38 patients)
43. * Seroyer ST, Musahl V, Harner CD. Management of the acute knee dislocation: the Pittsburgh experience. Injury. 2008;39(7):710-718. (Review)
44. Brooks RA, Ribbans WJ. Diagnosis and imaging studies of traumatic hip dislocations in the adult. Clin Orthop Relat Res. 2000(377):15-23. (Review)
45. Roberts JR, Hedges J. Roberts and Hedges’ Clinical Procedures in Emergency Medicine. 4th ed. Philadelphia, PA: Elsevier; 2004. (Textbook)
46. Gimber LH, Scalcione LR, Rowan A, et al. Multiligamentous injuries and knee dislocations. Skeletal Radiol. 2015;44(11):1559-1572. (Review)
47. Klineberg EO, Crites BM, Flinn WR, et al. The role of arteriography in assessing popliteal artery injury in knee dislocations. J Trauma. 2004;56(4):786-790. (Retrospective study; 55 patients)
48. * Nicandri GT, Chamberlain AM, Wahl CJ. Practical management of knee dislocations: a selective angiography protocol to detect limb-threatening vascular injuries. Clin J Sport Med. 2009;19(2):125-129. (Review)
49. Jaskulka RA, Fischer G, Fenzl G. Dislocation and fracture-dislocation of the hip. J Bone Joint Surg Br. 1991;73(3):465-469. (Retrospective study; 54 patients)
50. Hillyard RF, Fox J. Sciatic nerve injuries associated with traumatic posterior hip dislocations. Am J Emerg Med. 2003;21(7):545-548. (Retrospective study; 106 patients)
51. Eyi YE, Arziman I, Kaldirim U, et al. Fascia iliaca compartment block in the reduction of dislocation of total hip arthroplasty. Am J Emerg Med. 2014;32(9):1139. (Case report; 1 patient)
52. * Vinson DR, Hoehn CL. Sedation-assisted orthopedic reduction in emergency medicine: the safety and success of a one physician/one nurse model. West J Emerg Med. 2013;14(1):47-54. (Prospective study; 442 patients)
53. Yang EC, Cornwall R. Initial treatment of traumatic hip dislocations in the adult. Clin Orthop Relat Res. 2000(377):24-31. (Review)
54. * Frymann SJ, Cumberbatch GL, Stearman AS. Reduction of dislocated hip prosthesis in the emergency department using conscious sedation: a prospective study. Emerg Med J. 2005;22(11):807-809. (Prospective study; 101 patients)
55. Schafer SJ, Anglen JO. The East Baltimore lift: a simple and effective method for reduction of posterior hip dislocations. J Orthop Trauma. 1999;13(1):56-57. (Prospective study)
56. Hendey GW, Avila A. The Captain Morgan technique for the reduction of the dislocated hip. Ann Emerg Med. 2011;58(6):536-540. (Prospective study; 77 patients)
57. Dan M, Phillips A, Simonian M, et al. Rocket launcher: a novel reduction technique for posterior hip dislocations and review of current literature. Emerg Med Australas. 2015;27(3):192-195. (Prospective study; 6 patients)
58. Boss SE, Mehta A, Maddow C, et al. Critical orthopedic skills and procedures. Emerg Med Clin North Am. 2013;31(1):261-290. (Review)
59. * Howells NR, Brunton LR, Robinson J, et al. Acute knee dislocation: an evidence based approach to the management of the multiligament injured knee. Injury. 2011;42(11):1198-1204. (Review)
60. Dedmond BT, Almekinders LC. Operative versus nonoperative treatment of knee dislocations: a meta-analysis. Am J Knee Surg. 2001;14(1):33-38. (Meta-analysis; 206 patients)
61. 61. Cole BJ, Harner CD. The multiple ligament injured knee. Clin Sports Med. 1999;18(1):241-262. (Review)
62. Jiang W, Yao J, He Y, et al. The timing of surgical treatment of knee dislocations: a systematic review. Knee Surg Sports Traumatol Arthrosc. 2015;23(10):3108-3113. (Systematic review; 150 patients)
63. Horn A, Ufberg J. Management of Common Dislocations. In: Roberts JR, ed. Roberts and Hedges’ Clinical Procedures in Emergency Medicine. 6th ed. Philadelphia, PA: Elsevier; 2014:954-998. (Textbook chapter)
64. Thangarajah T, Giotakis N, Matovu E. Bilateral ankle dislocation without malleolar fracture. J Foot Ankle Surg. 2008;47(5):441-446. (Case report; 1 patient)
65. Grotz MR, Alpantaki K, Kagda FH, et al. Open tibiotalar dislocation without associated fracture in a 7-year-old girl. Am J Orthop (Belle Mead NJ). 2008;37(6):E116-E118. (Case report; 1 patient)
66. Kellam P, Ostrum RF. Systematic review and meta-analysis of avascular necrosis and posttraumatic arthritis after traumatic hip dislocation. J Orthop Trauma. 2016;30(1):10-16. (Systematic review and meta-analysis; 1707 patients)
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68. Yahya MM, Mwipatayi BP, Abbas M, et al. Popliteal artery injury: Royal Perth experience and literature review. ANZ J Surg. 2005;75(10):882-886. (Review)
69. Meek RM, Allan DB, McPhillips G, et al. Epidemiology of dislocation after total hip arthroplasty. Clin Orthop Relat Res. 2006;447:9-18. (Meta-analysis; 14,314 patients)
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Episode 11 Shownotes | Managing Dislocations of the Hip, Knee, and Ankle in the Emergency Department (Trauma CME)

Lower-extremity dislocations are less common in the emergency department (ED) than shoulder and elbow dislocations, and emergency clinicians’ experience with evaluation and reduction techniques is often limited. Nonetheless, these dislocations can be serious because of their association with vascular injury. This episode discusses the mechanism of injury, diagnostic approach, treatment plans, and potential complications of dislocations of the hip, knee, and ankle.

This episode of EB Medicine’s EMplify podcast is hosted by Jeff Nusbaum, MD, and Nachi Gupta, MD, PhD. This month’s corresponding full-length journal issue of Emergency Medicine Practice was authored by Dr. Caylyne Arnold, Dr. Zane Fayos, Dr. David Bruner, and Dr. Dylan Arnold. It was peer reviewed by Dr. Melissa Leber and Dr. Christopher Tainter.

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 Managing Dislocations of the Hip, Knee, and Ankle in the Emergency Department  - Calculated Decisions - Trauma CME

Bastion Classification of Lower Limb Blast Injuries

• Introduction
• Points & Pearls
• Why and When to Use, and Next Steps
• Calculator Review Author
• Evidence Appraisal
• Calculator Creator
• References

Introduction

 The Bastion Classification criteria stratify explosion related lower limb injuries into 5 categories to guide treatment.

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Points & Pearls

• The validation study of the Bastion Classification (Jacobs 2014) was not designed to correlate class of injury with outcomes such as mortality, transfusion requirements, or definitive amputation level.
• The Bastion Classification correlates better in blast injuries resulting in traumatic amputations than in segmental injuries.
• Because not all injuries involve complete traumatic amputation of a limb, this classification is supplemented by the suffix “S” to denote a segmental injury, defined as the presence of potentially viable tissue distal to the most proximal injury.
• Associated injuries to the intraperitoneal abdomen, genitalia and perineum, pelvic ring, and upper limbs are important in treatment and operative planning, so these are denoted by additional suffixes A through D, respectively.
• Prehospital application of a tourniquet can effectively obtain hemorrhage control. The study validating the Bastion Classification (Jacobs 2014) had 98 injuries requiring pneumatic tourniquets out of 179 injuries (55%). A recent study in 2017 by Scerbo et al reported that patients who presented without prehospital tourniquets received more transfusions in the first hour of arrival (55% vs. 34%, P = .02) and had increased mortality from hemorrhagic shock (14% vs. 3%, P = .01).

Why and When to Use, and Next Steps

Calculator Review Author

Jennie Kim, MD

Travis Polk, MD

Evidence Appraisal

A panel of military surgeons, Jacobs et al, developed the Bastion Classification and performed a prospective validation study with 103 patients who sustained 179 lower limb injuries caused by improvised explosive devices treated at Camp Bastion, Afghanistan, from November 2010 to February 2011.

The primary aim of the proposed classification was to provide a pragmatic, comprehensive, and clinically relevant system to better facilitate the transfer of information. Currently existing lower limb injury classification systems fail to describe the complete injury pattern or correlate with management. The Internal Committee of the Red Cross classification is broad and does not provide information on the severity of injury. The Mangled Extremity Severity Score (MESS), Gustilo and Anderson, and Müller AO classifications do not provide information on injury level. The Müller AO classification also does not take into account soft tissue injury. The secondary aim of the study by Jacobs et al was to facilitate the assessment of interventions. The Bastion Classification did show a predictable association with the level of initial musculoskeletal debridement and/or amputation and the level of vascular control.

The original study was not designed to correlate class of injury with outcomes such as mortality, transfusion requirements, or definitive amputation level, and thus, this information is not provided in the publication nor in the conclusions made.

A study in 2013 by Lundy and Hobbs looked at 67 patients with 117 injured limbs caused by dismounted blast exposure. The authors noted that the Bastion Classification appeared to be predictive of initial musculoskeletal treatment but was less useful in predicting the need for proximal vascular control, especially in the most common Class 3 injuries. The original study by Jacobs et al showed that Class 3 injuries correlated with a higher rate of intra- or extraperitoneal iliac vessel control (23% of 83 Class 3 injured limbs without associated abdominal injuries) compared to the study by Lundy et al that only had 1 patient with a Class 3 injury without associated abdominal injury and 6 (5%) of all injured limbs requiring iliac vessel control. The 2013 study does not comment on correlation of the Bastion Classification to mortality rates.

Calculator Creator

Neal Jacobs, MD

References H4

Original/Primary Reference

• Jacobs N, Rourke K, Rutherford J, et al. Lower limb injuries caused by improvised explosive devices: proposed ‘Bastion Classification’ and prospective validation. Injury. 2014;45(9):1422-1428.

Validation

• Lundy JB, Hobbs CM. Bastion Classification’: evolution of experience mandates caution when considering using class as predictor for method of temporary vascular control. Injury. 2013;44(11):1671-1672.

Other References

• Scerbo MH, Holcomb JB, Taub E, et al. The trauma center is too late: major limb trauma without a pre-hospital tourniquet has increased death from hemorrhagic shock. J Trauma Acute Care Surg. 2017;83(6):1165-1172.
• Cannon JW, Hofmann LJ, Glasgow SC, et al. Dismounted complex blast injuries: a comprehensive review of the modern combat experience. J Am Coll Surg. 2016;223(4):652-664.e8.
• Coupland RM, Korver A. Injuries from antipersonnel mines: the experience of the International Committee of the Red Cross. BMJ. 1991;303(6816):15909-15912.
• Gustilo RB, Mendoza RM, Williams DN. Problems in the management of type III (severe) open fractures: a new classification of type III open fractures. J Trauma. 1984;24(8):742- 746.
• Müller ME, Nazarian S, Koch P. The Comprehensive Classification of Fractures of Long Bones. Berlin: Springe Verlag;1987.
• Brown KV, Ramasamy A, McLeod J, et al. Predicting the need for early amputation in ballistic mangled extremity injuries. J Trauma. 2009;66(4 Suppl):S93-97; discussion S97-98.

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